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Travel Claims Form

(Please fill in all the information requested before submitting the form)

Fields mark (*) Are fields

  The Insured
Policy Number: * Claim Number: * Name of Insured:*
  Policy Holder
Policy Holder Details:*
Address:*
Parish:*
Occupation: *
Business: *
Telephone Number: *
  Personal Luggage
Name of Owner: * House/Lot #: * Road/Avenue: *
Area in PA: * Parish Area: * Parish: *
Date of Loss or Damage:* Time of Loss or Damage: * Date advised to Police: *
Circumstances of loss or damage:*
  Police Station
Address of Police Station: *
House/Lot #:* Road/Avenue: *
Area in PA:* Parish Area: * Parish: *
If luggage or money is insured under any other Policy, please state the name of address of insurers *
Name of Insurer:* House/Lot #: * Road/Avenue: *
Area in PA:* Parish Area: * Parish: *
  Details of Luggage
No. of Articles Description When Purchased Where Purchased Cost Paid Amount Claimed
  Personal Accident/Loss of Deposits
Name of Injured person: * Date of Birth: * Occupation: *
House/Lot #: * Road/Avenue: *
Area in PA: * Parish Area: * Parish: *
Description of Accident &/or illness:*
Date of Accident: * Time: a.m./p.m. * Nature of Injury: * Name of Doctor who attended: *
House/Lot #: * Road/Avenue: *
Area in PA: * Parish Area: * Parish: *
Has a similar injury been sustained before?* If so, when? * Name of Usual Doctor: *
Yes No
House/Lot #: * Road/Avenue: *
Area in PA: * Parish Area: * Parish: *
During what period was the injured person totally disabled from attending to any part of his occupation or profession? *
From To
If total disablement continues, a medical certificate will be required from the injured person's usual Doctor.
FOR CLAIMS FOR 'LOSS OF DEPOSITS' PLEASE STATE
HOTEL/ACCOMODATION COSTS TRANSPORT
1. Amount of Deposit
2. Percentage returned by carrier
Net amount claimed
Date: Signature of Insured:
  Medical and Other Expenses
Name of Person Concerned: * Date of Birth: *
House/Lot #: * Road/Avenue: *
Area in PA: * Parish Area: * Parish: *
Nature of injury or illness: * Date: * Cause of injury or illness: *
Name of Doctor who attended: * House/Lot #: * Road/Avenue: *
Area in PA: * Parish Area: * Parish: *
If the cause was illness, has the person concerned previously suffered similar illness? * If so, when? *
Yes No
Details of expenses claimed. *
Receipts and documents supporting this claim are to be sent with this form.
I declare that the particulars given on this form are, to the best of my knowledge, true and complete.
I declare that the particulars given on this form are to the best of my knowledge, true and complete.
Date: Signature of Insured:
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